Connecticut to launch Medicaid maternity bundle Jan. 1 after CMS State Plan Amendment approval

The Connecticut Department of Social Services will begin an episode‑based maternity payment model Jan. 1, 2025, after receiving CMS approval via a State Plan Amendment, agency presenters said during a December provider forum.

DSS said the CMS approval was granted on Nov. 20, 2024, and the State Plan Amendment is effective Jan. 1. The department described the “maternity bundle” as an episode of care that runs from conception through 90 days postpartum and includes new covered services such as doula and lactation support.

Why it matters: DSS officials said the bundle is intended to strengthen maternal health, improve equity and outcomes, and reduce unnecessary spending. Presenters cited that Medicaid covered about 45% of Connecticut births and that the state’s C‑section rate was about 33% in 2020, framing the payment change as part of broader efforts to change incentives and accountability for perinatal care.

How it will work: Under the new model, participating practices that meet eligibility criteria will receive provider‑specific case‑rate payments beginning in the second trimester and continuing through 90 days postpartum. DSS described three trigger criteria to initiate a case rate: an accountable practice that performs 30 or more deliveries per year, submission of claims with a qualifying trigger diagnosis plus an E&M code, and billing with the qualifying place of service and maternity specialty (for example OB, maternal‑fetal medicine, certified nurse midwife or women’s health nurse practitioner). DSS said the program will phase in: from Jan. 1–Mar. 31 case rates will be initiated only for second‑trimester triggers; effective April 1, practices can trigger and receive case rates covering second trimester, third trimester and postpartum.

Payments and reconciliation: DSS explained case‑rate payments will be generated monthly and appear on remittance advice showing client ID, client name, date of service and the case‑rate payment. The department will provide a supplemental payment report (DSS said it expects the report to be monthly and to include client identifiers, practice TINs, accountable provider AVRS IDs, payment month/year, payment amounts, recoupment indicators and transaction numbers) and quarterly dashboard and reconciliation reports to support practices in tracking performance and payments.

Quality, risk adjustment and provider concerns: DSS acknowledged provider concerns that the measures could unfairly penalize clinicians who care for higher‑risk patients, particularly maternal‑fetal medicine (MFM) specialists. Presenters said the maternal adverse event measure used in the model is risk‑adjusted and that the shared‑savings scoring uses two pathways — peer comparison and improvement over time — with the higher of the two determining a practice’s share of savings. DSS also said it is incorporating clinical and social risk adjustment in multiple measures and will monitor access to ensure practices are not disincentivized from treating higher‑risk patients.

Reporting and administrative workflow: DSS and implementation partners said practices will receive quarterly performance dashboards and that some reporting measures will require encounter forms (for items such as breastfeeding and behavioral risk assessment), while others will be claims‑based. DSS currently recommends manual, per‑patient submission for the encounter form at launch but said it will continue exploring bulk‑upload or supplemental file options to reduce administrative burden for smaller practices.

Practical examples and attribution: DSS clarified that more than one practice can receive the case rate for a given month if co‑management occurs; the case rate will not be prorated. The department also said hospital facility payments will remain fee‑for‑service while case rates cover professional services; historically higher professional costs are reflected in the case‑rate calculations.

Next steps and support: DSS emphasized ongoing stakeholder engagement after launch, including provider forums and CHN provider engagement representatives available for one‑on‑one support. The department said it will post program specifications, code lists and quality‑measure details on the DSS website and will update FAQs to confirm the supplemental report cadence and other technical details.

DSS quoted in the forum: “We have CMS approval to launch this through the State Plan Amendment process that was granted approval on 11/20/2024 and has effective date of January 1,” the department said during the presentation.

The department asked providers to continue submitting questions and feedback and said it will monitor implementation and revisit technical and measurement details as the program matures.